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This is Brent of the Brookbush Institute
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at the Independent Training Spot. Today
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we're going over goniometric assessment, specifically dorsiflexion. So
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we've been talking about this large overhead squat assessment which is a
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great postural assessment, gives you an indication of the compensation pattern
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and all of the joints involved in the dysfunction that you're looking at. But
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now you need to get a little bit more specific, we need to look joint for joint
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and see where we are restricted, and if possible put some objective data to that
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restriction, that's a number that we can actually show progress over time. I'm
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going to have my friend Mike Tierney come out from metropolitan fitness, he's going
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to help me demonstrate. He was nice enough today to show off his legs and
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get taped up. So dorsiflexion right, dorsiflexion is this joint motion here.
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Anytime we do goniometric assessment they're going to talk about making two
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lines, one for your stabilization arm which is the arm that attaches to the
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protractor of the goniometer, and one for your movement arm. So this is
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just, there's degrees listed here, here's my movement arm, pivot point,
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stabilization arm. You can see with Mike to make things a little easier for the
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camera I've gone ahead and taken big orange pieces of rock tape, and outlined
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the lines that we're going to use for dorsiflexion goniometric assessment.
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Norkin and White, Norkin and Whites is kind of the the standard text
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for goniometric assessment, they talk about the stabilization arm going
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through a line, an imaginary line that we draw from fibular head to lateral
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malleolus, and so that's that's what I've outlined here with the rock tape, and
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then they're going to talk about the movement arm being parallel to the fifth
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metatarsal. So essentially what we're measuring is
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how many degrees do we see of movement between these two lines. Now one of the
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weird things about goniometric assessment is it's in degrees of motion.
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So despite this being nearly a 90-degree angle, since this is neutral dorsiflexion
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this is zero. Alright normal dorsiflexion is between 15 and 20
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degrees, all right so we want to see 15 to 20 degrees of motion. The weird thing
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about ankle dorsiflexion range of motion is because these muscles are so strong
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right, they're used to the Mikes entire body weight. Every time he takes a step,
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rather than passive range of motion which he probably, you know we don't have
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that much passive range of motion at the ankle. We do active assistive range of
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motion so that we overcome some of this muscular restriction. So I'm going to have
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Mike actually pull up on this assessment, and then I'm going to give them a little
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over pressure almost like I was simulating the ground during gait. So I'm
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going to have Mike lay back in a supine, make sure they're not sitting up on you as
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that can create some neural restriction. I'm going to have him scoot down just a
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little bit for me, so those ankles hanging off. I'm going to put my
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stabilization arm over the line I was talking about, fibular head to lateral
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malleolus. My pivot point, in Norkin and White they talk about being over the
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lateral malleolus, and then this movement arm is going to be parallel to this line
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here. So I'm going to have Mike go ahead and pull up for me dorsiflex. Be very
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careful when you guys do this that you're paying attention to how he
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dorsiflexes, if he dorsiflexes and everts, you're going to get a
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different number and that's not going to be an accurate assessment of pure
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dorsiflexion. So you can either kind of assess the talus and make sure that
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it's even on both fingers here, by palpating the talar neck, or you can
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kind of monitor that second and third toe, but make sure as he's pulling up
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there it's nice and pure. I'm going to go ahead and put movement arm
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over that line, pivot point lateral malleolus. I'm going to give them a
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little over pressure, make sure he's pulling up. I'm going to look back here,
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make sure my lines are parallel, and I get 18 degrees of dorsiflexion. Mike's
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got some good dorsiflexion. Alright so one more time guys, I'm actually going to
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show you a little trick, rather than going parallel to this line it's
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actually easier and it doesn't change your measurement at all to move your
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goniometer back, keep this line the same but pretend it extends a little
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farther. So it's still fibular head the lateral malleolus, but keep it going put
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your pivot point on the fifth metatarsal, and now what you can do is you almost
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like free up a hand, because now you can kind of just push the goniometer
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the movement arm and his foot into over pressure, at the same time make
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sure everything aligns. Alright the other thing I wouldn't do is sit in this
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position here, I would be sitting on the other side and once again I get 18
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degrees. Hopefully you guys can see how that would make it a little easier by
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just moving that back, I got one hand back because this hand was able to push
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both of the movement arm and his foot. Now like I said I wouldn't be here on
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this assessment, I would be here, I just didn't want to turn my back to the
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camera and I wanted you guys to be able to see what I was doing, thank you Mike.
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Now the big question with goniometry is what do we do with it. It's very
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important when we choose our assessments that they have purpose. All assessments
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if I were to summarize are going to kind of fall into two categories, there either
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diagnostic assessments, or assessments that clear our patients and clients for
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intervention. That is is that intervention appropriate, or do they need
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to be referred out. Or we have assessments like goniometry which
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hopefully are going to have an impact on our exercise and intervention selection.
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In order for dorsiflexion goniometry to have an impact on our intervention
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we need to know what restricts dorsiflexion, and that's where this graph
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behind us comes in. So we'll start with knowing what we're looking at, we're
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looking at active assisted range of motion 15 to 20 degrees. Mike had 17
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degrees, 18 degrees, So this might not be his biggest problem. We then look at end
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feel which for this particular measurement should be firm, that is
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you're going to feel not a hard stop like rock on rock, but more like a
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leather strap. It's going to it's going to be soft soft soft soft soft and then
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it's going to firm up pretty good, and there's going to be just the little
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gives, but not too much. Right and that's kind of a a muscular end feel because
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the primary restrictors for dorsiflexion are muscles, gastroc, soleus and fibularis.
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This probably kind of makes sense to you guys right, our commonly
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overactive plantarflexors are gastroc, soleus, and fibularis, that would make
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sense that they restrict dorsiflexion in a lot of individuals. So how would that
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impact my intervention, maybe I'm going to release and lengthen these guys,
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release and stretch these guys. Well we can take this many many many steps
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further, and this is where your knowledge of functional anatomy comes in. Let's say
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I didn't get a firm end feel but I got a hard end feel, a bone on bone right,
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that's that's more of a joint end feel, and I'm going to start thinking maybe
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there's something going on with this talus right, because tibiotalar
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dysfunction as well as distal tib fib dysfunction can also play a role in
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dorsiflexion restriction. Maybe I check this out, or maybe I do a
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technique like my ankle mobilization and I still don't get back to 15 to 20
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degrees of dorsiflexion. Well then maybe I start looking at fascial components. I
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know my guys out there doing instrument assisted soft
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tissue mobilization, or those you guys doing pin and stretch, those fascially
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directed techniques, well you need to know what fascial structures could
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potentially restrict dorsiflexion, being the posterior capsule, posterior crural
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fascia, my posterior talofibula ligament, my calcaneal fibula ligament or my
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posterior halal tibial ligament. I will say that it's pretty rare but it might
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be worth knowing what nerve could restrict dorsiflexion as well. I think in
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this particular position with Mike's hip in neutral it'd be pretty rare that we
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would start getting tibial or sciatic nerve issues, and if we did we would
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probably want to do further testing to figure out exactly how it's restricted.
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But you guys can see here this graph is going to keep coming back in every
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goniometric assessment video I do. What are the muscles, joints, fascial and neural
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structures that could restrict that joint motion, and my whole intent is to
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help direct how am I going to make this better. That's it. I will show further
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assessments so that this board of a bunch of things, becomes maybe one or two
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things, or maybe just a few things to go ahead and address. But starting here at
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the very least, even if you didn't know any further assessments. Look at all of
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the potential options you have to getting somebody back to optimal range
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of motion. So I'm going to bring Mike back out here for one more practice of
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this dorsiflexion range of motion.
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Just a quick recap, he's going to lay back in supine position, his knee in
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soft extension. I'm going to draw that line from fibular head to lateral
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malleolus. You guys know I like to move the goniometer down so that my
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stabilization arm is still through that line, but my pivot point is now on the
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fifth metatarsal, and then I'm going to have him pull up, make sure his
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dorsiflexion is pure. I'm going to realign my goniometer, i'm going to give
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them a little over pressure, and i get 18 degrees. I hope that helps you not only
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do goniometric assessment, but use goniometric assessment. I look forward to
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hearing about your outcomes.